Evaluating the Impact of AAC Interventions in Reducing Hospitalization-related Stress: Challenges and Possibilities (summary)



A lot of children with communication difficulties need to use hospital services frequently and have a legal right to “be informed, to communicate, and to express opinions using their preferred means of communication including augmentative and alternative forms” (United Nations 2006). However hospitals often rely on parents to act as interpreters and have little knowledge of augmentative and alternative communication (AAC) and communication disabilities.

Hospital visits and procedures can be distressing for children and their families and an inability to communicate feelings about this or to understand what is happening can increase stress.

The reduction of stress and anxiety levels has been found to be beneficial in successful rehabilitation.

There has been limited research into the possible value of AAC use in hospital with children with long term conditions, most is related to adults. The few studies that have been carried out have indicated that AAC can be successfully used in hospital settings. They also suggest that there is a need for more information about communication disabilities and a consistent approach to the use of AAC strategies in healthcare settings.

This paper looks into some of the ways in which the effects of using AAC interventions in health care can be measured.

What did they do?

The KomHIT (communication in care settings using communicative support and IT) model was used in a children’s day surgery ward and the effects of its use on stress and anxiety in children and their parents were measured using an anxiety inventory. The authors also investigated whether changes in stress levels could be measured using levels of salivary cortisol.

The KomHIT intervention is designed to support the communicative rights of children during medical and dental care. It aims to promote generalised use of AAC strategies, usually as pictorial supports, routinely in healthcare for children. The intervention includes educational resources for use with staff and communication tools and materials.

A month before the intervention period began all nursing staff in the day surgery unit attended a one day education course about communication. AAC resources designed to suit the needs of the ward were presented and demonstrated with staff given opportunities to practise their use. These same AAC resources were used in the intervention, being sent to each family before they attended hospital. Included among these were a visual schedule with six pictures of the main things that would happen during the child’s appointment and a 30 symbol communication board to support conversation about day surgery.

Parents were told how to use the materials and encouraged to do so before and after surgery as well as taking them to the hospital.

The nurses used visual schedule books to explain what would happen to each child and to allow the child to ask questions or comment. The children removed pictures after each step was complete. The nurses also had access to the communication board but reported that the schedules were most useful.

25 children, aged between 3 and 15, and their families took part in the study. 18 were assessed before the intervention began, the comparison group, and 7 after implementation of the intervention.

Samples of the children’s saliva were collected on admission, during the day and later at home for analysis of cortisol levels. A modified form of an anxiety assessment was used with the children on admission and discharge. The parents completed the same assessment in an unmodified form. The children’s medical records were also checked retrospectively to see if they had needed to be given premedication as this was done for children identified by nurses as anxious and/or tense.

What did they find?

15 children gave saliva samples. Informal feedback from staff suggested that the schedule for the saliva test procedure was useful.

The salivary cortisol results for the two groups of parents, those included in the intervention and the comparison group, were similar. There were some differences between the two groups of children, being lower for the intervention group, though some of their results could not be used.

The anxiety measurement did not show significant differences between groups of parents or children.

None of the seven children in the intervention group were found to have needed premedication, five of the comparison group had been give some form of premedication.


The study showed that measures routinely used in healthcare can be used to evaluate the effects of access to AAC strategies on children with communication disabilities if they are adapted appropriately.

The authors also suggest that all children, with and without communication disabilities should have access to AAC strategies to support their communication in hospital and that the impact of this should be evaluated.


The study had a small number of participants and many uncontrolled variables. Some possible participants opted not to take part in the research study as they felt the extra elements would be too much in addition to the surgery.

As some cortisol measures has to be excluded it is possible that this might not be the best physiological measurement to use to monitor stress.

The limited number of questions in the adapted anxiety measure and the small number of participants make interpretation of the results difficult and, even with pictorial stimuli children with cognitive difficulties might have found it difficult to understand.


Things you may want to look into:

Patient Communication in Health Care Settings: new Opportunities for Augmentative and Alternative Communication

A Metasynthesis of Patient-Provider Communication in Hospital for Patients with Severe Communication Disabilities: Informing New Translational Research

Nursing the patient with severe communication impairment

A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication

Communication rights and disability online: Policy and technology after the World Summit on the Information Society

Added to site August 2016